Ch. 10 Vital Signs Quiz

Which finding would the nurse consider abnormal when obtaining the heart rate of a 20-year-old patient who runs marathons?

105 bpm The normal range for the heart rate of an active 20-year-old patient is between 55 to 90 beats per minute. Therefore the heart rate of 105 beats per minute would be considered abnormal.

Which respiratory rate is normal for a 9-year-old patient?

22 bpm The normal respiratory rate in a 9-year-old child is 18 to 24 breaths per minute, so a respiratory rate of 22 breaths per minute is a normal reading. The respiratory rate of 16 breaths per minute indicates bradypnea, which is slow breathing. The respiratory rates of 28 and 32 breaths per minute indicate rapid breathing, which is called tachypnea.

The nurse counts the pulse of a patient with an irregular heart rate for how many seconds?

60 If the nurse notices a patient's heart rate is irregular, the pulse should be counted for a full minute (60 seconds). Counting in 15-second intervals could be inaccurate by 4 beats per minute. If a patient's heart rhythm is regular, counting the pulse for 30 seconds and multiplying by 2 works well. Counting the pulse for 45 seconds does not provide an accurate way to convert to an equal minute.

A decrease in which characteristic is responsible for hypotension after an acute myocardial infarction?

Cardiac output The patient with acute myocardial infarction may have arrhythmias such as ventricular tachycardia, which may cause decreased cardiac output and hypotension. Decreased total blood volume causes hypotension but is caused by hemorrhage, not myocardial infarction. A decrease in blood cholesterol levels does not cause hypotension. Decreased peripheral vascular resistance causes hypotension but is related to vasodilation rather than myocardial infarction.

Which is an appropriate step to take before assessing a patient's blood pressure?

Check that the patients feet are flat on the floor For the most accurate blood pressure reading, the patient's feet must be flat on the floor. Crossed legs artificially elevate the blood pressure. The bladder balloon should not be removed from the wrap because it gives a false high blood pressure reading. The patient's arm should be at heart level, not above it. The patient's skin must be bare to obtain the most accurate reading; therefore the nurse does not protect the patient's skin from the cuff with cloth.

Which nursing intervention will help the nurse accurately measure respiratory rate in an obese patient?

Feel the breaths by placing a hand on the patient's abdomen The nurse would measure respiration in an obese patient by placing a hand on the upper chest or the abdomen to feel the breaths, as observation alone may be insufficient. The nurse would use 30-second intervals to measure the respiratory rate to prevent +4 to -4 deviation in the results; a 10-second interval is too short to be accurate. The nurse would not inform the patient before assessing breathing, because a sudden awareness of breathing may alter the normal pattern and may give a false measurement. The nurse would measure the normal breathing pattern of a patient, but would not instruct the patient to breathe deeply while assessing him or her.

The pulse of a patient with acute anxiety would have which characteristic?

Full and bounding A full and bounding pulse denotes an increased stroke volume by the heart, which can be increased when the patient is anxious. A person who is suffering an anxiety attack will not have a normal pulse. A weak and thready pulse denotes a low stroke volume, which is seen in severe conditions such as hemorrhagic shock. The absence of pulse is an abnormal finding, but an anxiety disorder does not cause it.

Which symptoms are expected in a patient suffering from an acute myocardial infarction? Select all that apply.

Hypotension Cool, clammy skin Shoulder and jaw pain An acute myocardial infarction causes decreased cardiac output in the patient, leading to hypotension. In patients with acute myocardial infarction, the superficial blood vessels constrict to shunt blood to the vital organs; therefore the patient has cool and clammy skin. The patient with acute myocardial infarction may develop shoulder and jaw pain because the afferent sympathetic fibers enter the spinal cord from levels C3 to T4, accounting for a variety of locations and radiation patterns of chest pain; discomfort may radiate to the neck, lower jaw, left arm, and left shoulder, or occasionally to the back or down the right arm. The patient with acute myocardial infarction may have confusion, but not depression. Hypohidrosis is decreased sweating due to impaired sweat glands. The patient with acute myocardial infarction may have profuse sweating or diaphoresis, but not hypohidrosis.

Which organ is considered the thermostat of the human body?

Hypothalamus The human body maintains thermostatic equilibrium by a feedback mechanism, regulated in the hypothalamus of the brain. Therefore the hypothalamus can be considered to be the thermostat of the human body. The pituitary is an endocrine gland that is located at the bottom of the hypothalamus. The primary function of the pituitary gland is hormone secretion. The pituitary gland does not help in thermoregulation. The brainstem is the posterior part of the brain that regulates heartbeat, breathing, and sleeping. The skin is the sentry that guards the body from environmental stresses such as trauma, pathogens, and dirt and adapts it to other environmental influences.

The nurse is measuring a patient's thigh blood pressure (BP). Which is the most important point that the nurse should remember about thigh pressure?

It is higher than in the arm Normally, thigh BP is higher than that of the arm. If thigh pressure is lower than the arm pressure, it indicates coarctation of the aorta. Thigh pressure should ideally be measured in adolescents or young adults. Though thigh pressure is preferably measured in a prone position, it can also be measured in the supine position. The knee needs to be bent while measuring thigh pressure in the supine position. Normally, the systolic value is 10 to 40 mm Hg higher in the thigh than in the arm, as is the diastolic pressure, but the pulse pressure does not necessarily change.

Which route would the nurse use to assess temperature with an electronic thermometer with a red-tipped probe?

Rectal An electronic thermometer with a red-tipped probe is used to measure rectal temperature. An electronic thermometer with a blue-tipped probe measures oral temperature. The axillary measurement is not preferred because when cold receptors are stimulated, the skin temperature rises and interferes with the reading. The nurse may not use the red-tipped probe to measure the temperature of the tympanic membrane. The tympanic membrane thermometer resembles an otoscope.

The blood pressure taken in which location will be the highest in the patient with coarctation of the aorta?

Upper arm Normally the thigh blood pressure is higher than in the arm, but a patient with coarctation of the aorta will have a lower thigh blood pressure due to constriction of the blood supply. The upper arm will provide the highest blood pressure reading, not the calf, thigh, or forearm.